ACN Provider Pre-Screening Form

Thank you for your interest in Arizona Care Network!
ACN is interested in learning more about your organization. Please complete this online pre-screen form to assist in our evaluation of your request to participate.

• Please review our participation requirements.

• The pre-screen should take approximately 5-7 minutes to complete.

• Once you start the survey, you must complete it in its entirety as the system will not allow you to save and complete at a later date.

Before we get started, please review the details below. ACN will request you acknowledge review of these items as part of the submission process. Please understand that completing this online pre-screen is not considered an application. Upon review of your submission, ACN will determine if your organization meets our current network needs and a formal ACN application will be sent under separate cover if we decide to move forward with the contracting process.

Rows	I Attest
• Completing the pre-screen is not a guarantee ACN will contract with your organization
• Upon submission of your request, you will receive an immediate, automated email indicating ACN received your request
• The automated request will be your only acknowledgement of your submission
• If ACN does not outreach within 10 business days of submission, there is not a current network need and no further correspondence will occur
• Please allow six months from original submission to resubmit a request to join the network
• Please do not send multiple requests as this will delay the review process

Is your organization’s primary location located in Maricopa County?

Is your organization currently affiliated with an active ACN practice or facility?

Are you a Pediatric office, comprised entirely of Pediatricians, inquiring about participation with Arizona Care Network?

Thank you for your interest in Arizona Care Network!